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  • Acute Kidney Injury in...

Acute Kidney Injury in Children: IAP Guidelines

AyeshaWritten by Ayesha Published On 2023-01-27T10:15:01+05:30  |  Updated On 2023-01-27T15:36:18+05:30
Acute Kidney Injury in Children: IAP Guidelines

Acute kidney injury (AKI) previously known as acute renal failure (ARF), is an important emergency where prompt and appropriate management is life-saving. AKI usually occurs in patients with previously normal renal function but may occasionally be superimposed on preexisting renal disease (acute-on-chronic renal failure). The incidence of AKI in pediatric intensive care unit (PICU) is around 30–40% with mortality rates of 40–50%.

The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Acute Kidney Injury in Children. The lead author for these guidelines on Acute Kidney Injury in Children is Dr. Mukta Manthan along with co-author Dr. Bipin Jose and Dr. Mihir Sarkar. The guidelines come Under the Auspices of the IAP Action Plan 2022, and the members of the IAP Standard Treatment Guidelines Committee include Chairperson Remesh Kumar R, IAP Coordinator Vineet Saxena, National Coordinators SS Kamath, Vinod H Ratageri, Member Secretaries Krishna Mohan R, Vishnu Mohan PT and Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan Kalyan.

Following are the major recommendations of guidelines:
Nomenclature and Classification:
Acute kidney injury is defined as an increase in serum creatinine by ≥0.3 mg/dL within 48 hours; or an increase in serum creatinine to ≥1.5 times baseline, which is known or presumed to have occurred within last 7 days; or a urine volume <0.5 mL/kg/h for 6 hours.
Acute kidney injury is further classified into three stages based on rise of serum creatinine or change in urine volume. It is recommended to use Kidney Disease: Improving Global Outcomes (KDIGO) classification for an early diagnosis of AKI so that measures are taken to prevent the progression of the condition.

TABLE 1: Classification of acute kidney injury (KDIGO classification).

AKI severity

Serum creatinine criteria

Urine output criteria

Stage I

1.5–1.9 times baseline Or

³ 0.3 mg/dL increase

<0.5 mL/kg/h for 6–12 hours

Stage II

Increase ³ 2–2.9 times baseline

<0.5 mL/kg/h for ≥12 hours

Stage III

3.0 times baseline Or

Increase in serum creatinine to ³ 4.0 mg/dL

Or

Initiation of renal replacement therapy Or

In patients <18 years, decrease in eGFR to

<35 mL/min per 1.73 m2

<0.3 mL/kg/h for 24 hours or anuria for 12 hours

(AKI: acute kidney injury; eGFR: estimated glomerular filtration rate; KDIGO: Kidney Disease: Improving Global Outcomes)
Causes:
The etiology of AKI has conventionally been classified as prerenal, intrinsic renal, or postrenal (Box 1). Prerenal AKI occurs due to inadequate systemic and/or renal circulation, due to either systemic hypovolemia or renal hypoperfusion. Both pre- and postrenal categories can, if prolonged, lead to intrinsic renal failure.

BOX 1: Causes of AKI.

Prerenal

  • Hypovolemia (dehydration, blood loss, and diabetic ketoacidosis)
  • Third space losses (septicemia and nephrotic syndrome)
  • Congestive heart failure
  • Perinatal asphyxia
  • Drugs (ACE inhibitors, NSAIDs, and diuretics)

Intrinsic

Acute tubular necrosis

  • Prolonged prerenal insult (see above)
  • Medications: Aminoglycoside, radiocontrast, and NSAIDs
  • Exogenous toxins: Diethylene glycol and methanol
  • Intravascular hemolysis and hemoglobinuria
  • Snake bite
  • Tumor lysis syndrome

Hemolytic uremic syndrome: Diarrhea associated (D+) and atypical (D-) forms Glomerulonephritis (GN)

  • Postinfectious GN
  • Systemic disorders: SLE, Henoch–Schönlein syndrome and microscopic polyangiitis
  • Membranoproliferative GN

Interstitial nephritis (drug-induced and idiopathic) Bilateral renal vessel occlusion (arterial and venous)

Postrenal

  • Posterior urethral valves and urethral stricture
  • Bilateral pelviureteric junction obstruction
  • Ureteral obstruction (stenosis, stone, and ureterocele)
  • Neurogenic bladder
(ACI: angiotensin-converting enzyme; AKI: acute kidney injury; NSAIDs: nonsteroidal anti-inflammatory drugs; SLE: systemic lupus erythematosus)
Clinical Features:
Presenting symptoms of AKI include oliguria with peripheral or pulmonary edema, suggesting fluid overload. Patients may have altered sensorium and convulsions due to advanced uremia, dyselectrolytemia, or hypertensive encephalopathy. The breathing may be rapid and deep due to acidosis. Features that suggest an underlying cause are presented in Table 2. Children with AKI due to acute interstitial nephritis, aminoglycoside toxicity, and perinatal asphyxia are often nonoliguric.

TABLE 2: Clinical features.

Clinical features

Likely diagnosis

Edema, hematuria, and hypertension

Acute glomerulonephritis

Dysentery, pallor, and jaundice

HUS

History of fluid loss with severe dehydration

ATN

Sudden passage of dark urine, pallor, and jaundice

Intravascular hemolysis

Interrupted urinary stream and palpable bladder

Obstructive uropathy

Abdominal colic, hematuria, and dysuria

Urinary tract calculi

Altered sensorium and seizures

Uremic encephalopathy

Acidotic breathing and pulmonary edema

Complications of AKI

(AKI: acute kidney injury; ATN: acute tubular necrosis; HUS: hemolytic uremic syndrome)
Investigations:
Investigations in patients with AKI are given in Box 2.

BOX 2: Investigations in patients with AKI.

Blood

  • Complete blood counts
  • KFT
  • Electrolytes (Na, K, and Ca)
  • Venous blood gas (pH and bicarbonate)

Urine

  • Urinalysis; culture (if symptoms of urinary infection)
  • Sodium, osmolality, fractional excretion of sodium (if available to differentiate prerenal from intrinsic AKI)

Radiology

  • Chest X-ray (for fluid overload and cardiomegaly)
  • Ultrasonography (identify obstruction and dilatation)
  • ECG for hyperkalemia

Investigations to determine cause

  • Peripheral smear examination, platelet, and reticulocyte count; blood and LDH levels; and stool culture (suspected hemolytic uremic syndrome)
  • Peripheral smear/RMAT—malaria
  • Leptospiral serology/microscopic agglutination test (gold standard)—leptospirosis
  • Blood culture—sepsis
  • Blood ASO, complement (C3), antinuclear antibody (ANA), antineutrophil cytoplasmic antibody (ANCA) (suspected acute and rapidly progressive GN)
  • Doppler ultrasonography (suspected arterial or venous thrombosis)
  • Renal biopsy in RPGN or nonresolving AKI
  • Micturating cystourethrogram (suspected obstruction)
(AKI: acute kidney injury; ASO: antistreptolysin O; ECG: electrocardiogram; GN: glomerulonephritis; KFT: kidney function test; LDH: lactate dehydrogenase; RMAT: rapid malarial antigen test; RPGN: rapidly progressive glomerulonephritis)
Management:
Management of AKI includes the management of complications and treatment of the specific underlying cause (Table 3).

TABLE 3: Management of complications.

Complications

Management

Others

Fluid overload

  • AKI regimen—insensible losses to be replaced by 5% Dextrose
  • UO to be replaced by NS
  • Modify according to Na level
  • Replace other losses

þ Consider dialysis

þ 0.5–1% weight loss per day

Pulmonary edema

  • O2/IV furosemide (2–4 mg/kg)
  • Respiratory support—HFNC/NIV/MV according to the patient condition
  • Chest X-ray

þ Lung ultrasound—B line

þ IVC assessment and ejection fraction

þ Monitor by CVP line

þ Dialysis (for fluid removal)

Hypertension

  • Symptomatic
    • Labetalol infusion @ 0.25–1 mg/kg/h
    • IV furosemide 2–4 mg/kg
  • Asymptomatic—oral nifedipine/ amlodipine 0.3–0.5 mg/kg
  • NTP—0.5–8 µg/kg/min (not to be given for >48 hours due to risk of toxicity)
  • Maintenance with amlodipine/ hydralazine

Metabolic acidosis

IV or oral NaHCO3

To monitor for fluid overload and hypernatremia

Hyperkalemia

  • Stop all potassium in IVF and medications
  • IV 10% Ca gluconate 1 mL/kg over 5–10 minutes if ECG changes
  • Salbutamol (2.5–5 mg) nebulization. Can be repeated after 20 minutes
  • Neutralizing glucose insulin drip— dextrose 0.5–1 g/kg and insulin 0.1–0.2 U/kg over 30 minutes. Can be repeated after 30 minutes
  • NaHCO3—1–2 mL/kg over 15–20 minutes if associated with metabolic acidosis
  • Potassium binding resins—sodium polystyrene 1 g/kg (oral/NG/rectal)

maximum 30 g

  • Monitor blood glucose for hypoglycemia

þ Continuous ECG monitoring

þ Repeat potassium level

Anemia

PCV transfusion at 5–10 mL/kg

Monitor for fluid overload

Hyper- phosphatemia

Phosphate binders such as calcium carbonate, and sevelamer hydrochloride (only if significant)

(AKI: acute kidney injury; CVP: central venous pressure; ECG: electrocardiogram; HFNC: high-flow nasal cannula; IV: intravenous; IVC: inferior vena cava; MV: mechanical ventilation; NG: nasogastric; NIV: noninvasive ventilation; NS: normal saline; PCV: packed cell volume; UO: urine output)
Nutrition:
Patients with AKI are usually catabolic and have increased metabolic needs. Adequate nutritional support is desirable with maximization of caloric intake. However, volume restriction necessary during the oliguric phase often imposes limitations. A diet containing 0.8–1.2 g/kg of protein in infants and 0.6–0.8 g/ kg in older children and a minimum of 50–60 Cal/kg should be given. The latter requirement can be met by adding liberal amounts of carbohydrates and fats to the diet. Once dialysis is initiated, dietary fluid and electrolyte restrictions can be made more liberal.
Kidney Replacement Therapy:
Indications of kidney replacement therapy (KRT) are given in Table 4.

TABLE 4: Indications of kidney replacement therapy (KRT).

Indications

Features

Fluid overload

  • Most common indication

þ Determines the outcome

þ >15% fluid overload resistant to diuretics

Metabolic acidosis

pH<7.2 despite bicarbonate therapy

Refractory hyperkalemia

K+ >6.0 or electrocardiogram (ECG) changes despite medical management

Hyponatremia/hypernatremia

Symptomatic

Uremia

Urea >160–200 mg/dL, encephalopathy

Create space for more fluid

Blood products, drugs, and nutrition

Removal of dialyzable toxins

Salicylate poisoning and phenobarbitone

Acute kidney injury requiring dialysis can be managed with a variety of modalities, including peritoneal dialysis (PD), intermittent hemodialysis (HD), and continuous renal replacement therapy (CRRT) (continuous venovenous hemofiltration or hemodiafiltration). The choice of dialysis modality to be used in managing a specific patient is influenced by several factors, including the goals of dialysis, the unique advantages and disadvantages of each modality, and institutional resources (Table 5). The initial KRT of choice in sick and unstable patients is often PD. It is popular because of the ease of initiation and effectiveness in children of all ages, including neonates.

TABLE 5: KRT modalities.

Modality

Potential setting in AKI

Advantages

Disadvantages

IHD

Hemodynamically stable

  • Rapid removal of toxins
  • Reduced exposure to anticoagulants

þ Lower cost than CRRT

  • Hypotension with rapid fluid removal

þ Dialysis

disequilibrium

CRRT

Hemodynamically unstable

  • Continuous removal of toxins

þ Hemodynamic stability

  • Easy control of fluid balance

þ No risk of increased

ICP

  • Slower clearance of toxins
  • Need for prolonged anticoagulation

þ Patient

immobilization

  • Increased cost

PD

  • Hemodynamically unstable

þ Coagulopathy

þ Difficult access

  • Under resourced region
  • Technically simple

þ No anticoagulation

þ Hemodynamic stability

þ Lower cost

  • No need for vascular access
  • Poor clearance

þ Protein loss

þ Risk of peritonitis

  • No control on rate of fluid removal

þ Hyperglycemia

(AKI: acute kidney injury; CRRT: continuous renal replacement therapy; ICP: intracranial pressure; IHD: intermittent hemodialysis; KRT: kidney replacement therapy; PD: peritoneal dialysis)
Reference:
  • Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter. 2012;2:1-138.
  • Levey AS, Eckardt KU, Dorman NM, Christiansen SL, Hoorn EJ, Ingelfinger JR, et al. Nomenclature for kidney function and disease: report of a Kidney Disease: Improving Global Outcomes (KDIGO) Consensus Conference. Kidney Int. 2020;97(6):1117-29.
  • Sutherland SM, Kwiatkowski DM. Acute kidney injury in children. Adv Chronic Kidney Dis. 2017;24(6):380-7.

The guidelines can be accessed on the official site of IAP: https://iapindia.org/standard-treatment-guidelines/

Indian Academy of Pediatric IAP Guidelines Acute kidney injury ARF creatinine glomerular filtration NSAIDs 
Source : Indian Academy of Pediatric, IAP Guidelines
Ayesha
Ayesha
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